Severe Sepsis Resuscitation Protocol: Non-Invasive Septic Patient with Lactate ≥ 4 mmol/L or MAP < 65 after 2 liters crystalloid WHO AND Goals of care are curative

• Administer 20-30 ml/kg isotonic crystalloid bolus over 20 minutes INITIAL • Send cultures of all likely sources of infection • Think of source control (Infected catheter? Operative intervention for infection? Drainable pus?) RESUSCITATION • Administer antibiotics to cover all likely sources of infection

If patient’s O2 saturation is < 90% on high fiO supplemental oxygen (non-rebreather mask), consider 2 SpO2 intubation and switching to invasive strategy.

Choose 1 Strategy • Dynamic IVC Ultrasound-Keep giving 500-1000 ml boluses of isotonic crystalloid until there is < 30% FLUIDS change in IVC size with inspiration. • Empiric Fluid Loading-Patients with severe sepsis/septic shock may require at least 6 liters of fluid during their acute resuscitation (first 6 hours of care).

• If MAP is < 65 after adequate fluid loading: RE-CHECKING - Place a full sterile central line in the IJ or SC vein (femoral site only if neck line not feasible); - Start vasopressors; titrate to a MAP ≥65; MAP - Consider switching to invasive protocol.

 Send repeat lactate when above goals are accomplished (Send a 2nd lactate at 3-hour mark, if not already sent) • If lactate has cleared by ≥ 10 % (or is not rising if original lactate was ≤ 2 mmol/L), go to disposition • If lactate is rising or has cleared by < 10%, choose 1 option: If Hb < 7: transfuse 1 unit of PRBC or Additional Fluids: if patient had empiric fluid loading, give an additional liter of TISSUE crystalloid or OXYGENATION Inotropes: especially if heart appears hypodynamic on echo. If calcium is low, replete that first. If not, administer dobutamine 5-20 mcg/kg/min. or If Hb 7-10: consider transfusion. Especially in elderly patients or patients with coronary artery disease  Send 3rd lactate, if it still has not cleared by ≥10%, continue with the above, trending lactates every 1‐2 hours until these two goals are met or switch to invasive strategy (Send 3rd lactate at the 6-hour mark, if not already sent) • Patients should get ICU consultation. If not an ICU candidate, should go to appropriately monitored DISPOSITION bed. • Periodically recheck patient for MAP ≥ 65, good mental status, and good urine output • Consider trending lactate every Q 2-4 hours. If it starts rising again, restart protocol

These protocols are for informational purposes only. Please review with your institution before using clinically.